Heart Beat:One January day during my time as surgical registrar in the Mater, I was working on the cardiac surgical team. I remember that cold day starting well enough, with a relatively routine cardiac case.
It was scheduled to be followed by a very difficult one. This was of a woman who had suffered from rheumatic fever in adolescence and consequentially developed valvular heart disease. This now affected three of her four heart valves.
Some years previously, she had undergone an operation to relieve the progressive blockage of one of these valves, by an operation called mitral valvotomy. This was undertaken by what we termed "closed heart surgery". A heart-lung machine was not used and the heart was not stopped.
Through an incision in the left side of the chest between the ribs, the lung was retracted out of the way and the covering around the heart (the pericardium) opened. This left the surgeon looking at the left side of the heart.
A purse string suture would have been used and a finger introduced into the left atrium (the chamber which collects oxygenated blood returning from the lungs). This finger would palpate and assess the degree of blockage. Then, an instrument called a Tubb's dilator would be introduced through the apex of the left ventricle of the heart (the chamber which pumps the blood to the body), and guided through the chamber to meet the exploring finger of the surgeon assessing the valve from above. Then the dilator would be opened in the orifice of the valve to stretch or even split it back to normal dimensions. The secret was not to do too little and, above all, not to do too much. The latter could lead to catastrophic leaking of the valve.
This lady had just such a problem from her original surgery and also had involvement of two other heart valves by the original illness. In everyday terms, she was going nowhere, a victim of end-stage cardiac disease, brought about by this once common condition. In those early days, the chance of coming through such a major operation, replacing these diseased valves with artificial substitutes, was no better than 50/50. It was a risk she accepted with stoic realism.
Her previous surgery made our problems worse. The heart had developed adhesions, both to its pericardium and the left lung. We prepared for a long, difficult day and so it proved. The heart was dissected free from adhesions and the tubes to connect the patient to the heart-lung machine were placed through heart muscle already weakened by the disease process. Eventually, all in place, the machine gradually took over the work of the heart and lungs, and cardiac activity and ventilation ceased.
Working as quickly as possible, the relevant heart chambers were opened, the diseased valves excised and their artificial replacements quickly sewn in place. The chambers and vessels were sutured, clamps removed, and gradually the heart resumed beating, fretfully, timorously at first, slowly strengthening as the support of the heart-lung machine was lessened and finally withdrawn. Initially, the heart struggled to maintain the burden, with irregular rhythm and generating little blood pressure to perfuse the vital organs. Bleeding was a problem, both from the surgical incision sites and wound, but also from the adhesions.
Clotting factors and blood platelets and whole blood were administered and one of the heart-lung technicians, not for the first time, donated a unit of her O-negative blood, as the situation appeared to drift away from us. Hours passed, and staff were relieved for tea and sandwiches, before return to the grim battlefield.
Finally, 10 hours after we had started, we closed the patient's chest and she was returned to our little intensive care unit and the care of
Sr M Attracta and her magnificent staff.
It fell to me to speak to the frightened, exhausted family, and in truth all the reassurance I could give was that she had come through the surgery. That was only one battle, the war for life had moved to the next campaign.
I was conscious then, and this remained with me throughout my surgical lifetime, that even the faintest glimmers of hope are magnified, making subsequent disappointment even more acute. I did not know then that Ivan Illich, philosopher and doctor, had written, "we must recover the difference between hope and expectation".
Ward rounds then at 10pm, a visit to the A&E department and then I returned to intensive care for the bedside vigil. I watched flickering monitors dispassionately telling of life's parameters, adjusting the drugs supporting the weak flame, and all the time wondering if there was anything else we could do.
The hospital and the world outside grew silent, cold and dark. My world was here, beside this bed, watching and waiting, helping and hoping. Almost imperceptibly, the situation steadied, there was less drainage from the chest and the cardiac support drugs were reduced.
At 3am, I spoke again to the family; guardedly optimistic, I said "things are going in the right direction". Finally, back to the residence, with the bizarre realisation that I had not had time to feel tired. In what seemed like seconds, the phone beside my bed rang. There was a major emergency in the A&E department; my day/night, whichever it was, was not over yet.
That's for next week, and by the way the brave lady above lived for 30 more years.
Maurice Neligan is a cardiac surgeon.